I used to blog at www.tryingtobeamedicalstudent.blogspot.com - then I stopped being a medical student and became a very junior doctor and blogged here.
Then, being a junior doctor and having little time, I sort of lost motivation for blogging and now I'm mostly found on Twitter - @TryingtobeaDr. Follow me there!

Sunday, 30 December 2012

Christmas #2 - the depressing side of the season

Although I wasn’t working on actual Christmas day, I was
working on Christmas Eve, and as mentioned previously, a 12 day stretch in the
run-up to Christmas. Christmas around the hospital can be a pretty depressing
affair, not because people have to stay in over Christmas and "isn’t that sad?" –
it is, but family visiting can make up for it, and when patients are properly
ill they seem content to be in the right place and receiving intensive medical
intervention, even if the timing is a bit rubbish. It’s depressing because of
the patients who want to be there, because hospital at Christmas is the best
they’ve got.

I’ve come across a number of patients recently (it’s more of
an issue in general surgery than it was in gynae) who are in hospital more
because they want to be than because they need to be. I can imagine the
outcries of “how is this possible, the NHS is stretched enough as it is!” but
the difficulty is that it is very difficult to boot patients out, kick them out
and onto the street. Discharge is a collaborative process, and requires the
patient’s input, or if the patient has no capacity for this input, then the
family or nursing home etc are involved.

There are the patients who were content at home, but came
into hospital for surgery, and rather enjoy the multi-bed ward and socialising
with other patients, the being cooked for, the lovely nurses and the nursing
care, and suddenly realise that home is desperately lonely and they don’t like
it anymore. This manifests itself as them realising, or proclaiming, that they
need care at home, and it then falls to the hospital to try to organise this,
which is a very lengthy process.

The time taken for this is why many patients, particularly
in an elderly care ward, will have days of “MFFD” recorded in the notes –
medically fit for discharge, i.e. awaiting the social situation to be sorted
out. Obviously sometimes this is absolutely essential, such as for elderly
people with a very high care requirement and complex medical needs, which
cannot be catered for in many care homes so it takes time to find the right
one. But there are others for whom the care given is less essential, they coped
without it previously and they are hardly less able to cope now, but it’s
become understood that it is required.

A specialist nurse I work with believes the cuts to day
centres have led to an increase in the number of patients who decide to stay in
hospital because home is lonely. If they could go to a regular day centre, home
wouldn’t be as lonely, and therefore hospital wouldn’t be as appealing. Yet
another example of how cuts can lead to increased costs elsewhere…

There are the patients who can’t possibly go home because
the problem they came into hospital with has not been fixed; they are still
suffering with pain or sickness or whatever brought them in. As much as I love
the idea that we can fix everyone who comes in the door, solve every problem,
and make everyone feel better, that is sadly not how it works in reality, but
sometimes is how it works in a patient’s head. It’s a sad thing, an unpleasant
situation, to send a patient home still suffering, and with an end to that
suffering not necessarily in sight – but sadly we are not magic.

Explaining to the patient that our thorough and extensive
investigations have shown no cause for their pain, there is no acute or
life-threatening problem, there is no cancer, there is no obvious disease,
there is essentially, nothing that can be fixed by a hospital stay, and nothing
that can’t be improved by some pain relief, regular review with the GP, and
community-based input such as physiotherapy, is not always a fruitful exercise,
and some patients end up staying longer in hospital because they think they
should be there.

Those patients are slightly less likely to stay in hospital
over Christmas, because they may eventually have somewhere better to be, once
they have realised that there really is nothing more that the hospital can do
to “fix” them, and being in hospital over Christmas is not the best thing that
life has to offer them, and the benefits of going home start to outweigh the
(perceived) benefits of staying in hospital.

The most depressing thing is the patients for whom staying
in hospital, or even worse, being readmitted to hospital following discharge,
is the best thing life has to offer them at Christmas. Their family either
don’t want them, or don’t make it clear to the patient that they are wanted, so
the patient has the sense of being a burden on the family, even if they aren’t
(this seems to be a depressingly common occurrence amongst the elderly). So
having a hospital bed over Christmas is the nearest they can get to seasonal
happiness.

That doesn’t reflect well on us as a society. Look after
your old people – if only for the sake of keeping the hospital beds free for
the people who really need them.

(I realise this may come across as hypocritical following my
complaints about my grandmother in my previous post, but she has never spent
Christmas alone. The responsibility is shared between my relatives, not because
she is a burden, but because we have a sense of duty to ensure she feels
welcomed and as happy as possible each Christmas, and regularly throughout the
year.)